Arkansas Medicaid Appeals and Fair Hearings: How to Appeal

If your Arkansas Medicaid was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is decided.1,2 That right comes from federal Medicaid law, but Arkansas sets its own clock: if DHS decided you are not eligible or is closing your Medicaid case, the Arkansas Department of Human Services (DHS) Office of Appeals and Hearings must receive your request within 30 calendar days of the date printed on your letter.2,3 To hold your coverage in place while you wait for a decision, you have to act even sooner, within 10 days, and ask in writing.2

In This Guide

• What You Can Appeal in Arkansas Medicaid
• Arkansas Medicaid Appeal Deadlines That Decide Your Case
• How to Keep Your Benefits During an Arkansas Medicaid Appeal
• Managed Care (PASSE) Appeals
• How to Request a Fair Hearing in Arkansas
• Frequently Asked Questions

What You Can Appeal in Arkansas Medicaid

Federal law gives Medicaid applicants and enrollees the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires Arkansas's Medicaid plan to offer a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness. The implementing regulation at 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously, denied a claim for eligibility or for covered services, issued a determination of their liability, or did not act on a claim with reasonable promptness, and separately to a nursing facility resident who believes the facility wrongly decided they must be transferred or discharged. The right has one stated limit: the agency need not grant a hearing if the sole issue is a federal or state law requiring an automatic change that adversely affects some or all beneficiaries.1

In Arkansas Medicaid, that right reaches across the program. You can appeal:

• An application denial (income, assets, household size, or citizenship and identity documentation)
• A termination or reduction of eligibility or covered services
• A renewal or recertification denial
• A prior-authorization denial or a level-of-care determination
• A PASSE managed-care plan's denial, reduction, suspension, or termination of a service

The same regulation that guarantees the hearing also covers managed-care members: 42 CFR 431.220 extends the right to any managed-care enrollee entitled to a hearing under the federal managed-care rules.1 What usually differs by situation is not whether you can appeal, but the deadline and the office that handles it.

Arkansas Medicaid Appeal Deadlines That Decide Your Case

Two deadlines govern an Arkansas appeal, and they are different numbers.

For an eligibility denial or a Medicaid case closure, the request window is 30 calendar days. The DHS Office of Appeals and Hearings must receive your hearing request within 30 calendar days of the date on the letter, or the request will be denied. The deadlines differ by situation, though: where Medicaid or ARKids First won't pay for a service you got from your provider, DHS's appeal page gives no day count, only that a late request will be denied, so ask DHS what your deadline is rather than assuming 30 days.2 Federal law under 42 CFR 431.221(d) sets the ceiling at 90 days from the date the notice is mailed, but a state may adopt a shorter operational window, and Arkansas uses 30 days.3 Read the date off your own notice and count from there, not from the day it reached your mailbox.

The continuation window is shorter, at 10 calendar days. That is the deadline that keeps your benefits flowing while the appeal is decided, and it is covered in the next section.

One more deadline protects renewals. If Arkansas ended your coverage only because you did not return a renewal form or requested information on time, you do not always have to reapply. Under 42 CFR 435.916, if your eligibility is based on modified adjusted gross income (MAGI) and you submit the renewal form within 90 days after the termination date, or a longer period the state elects, the agency must reconsider your eligibility without a new application. If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Arkansas may offer the same 90-day reconsideration but federal law does not require it, so ask DHS.4

How to Keep Your Benefits During an Arkansas Medicaid Appeal

Keeping your benefits during the appeal is called continuation, or "aid paid pending," and it is never automatic. You have to ask for it, and you have to ask in time.

Under DHS's instructions, to keep your benefits in place while the appeal is decided, DHS must get your appeal letter within 10 calendar days of the date on the notice, and in that letter you should specifically request that your benefits be continued, so that they can continue until the appeal is over.2

That instruction puts a federal rule into practice. Under 42 CFR 431.230(a), when the agency sends the required advance notice and you request the hearing before the date the action takes effect, the agency may not terminate or reduce your services until a decision is rendered after the hearing.2 Arkansas's 10-day instruction is how the state carries out that rule, so treat the earlier of the two dates on your notice as your real deadline. If DHS cut or ended your services without that advance notice, a separate rule applies: when you request a hearing within 10 days of receiving the notice (counted as 5 days after the date on it, unless you show it arrived later), the agency must reinstate your services until the hearing decision, unless the action came from applying federal or state law or policy.2

Continued benefits carry two conditions. They can stop before the decision only if both of these happen: it is determined at the hearing that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that your services will be cut or ended pending the decision. And if the agency's decision is later upheld at the hearing, 42 CFR 431.230(b) permits the agency to recover the cost of the services it provided only because your benefits kept running.2 When an adverse-action notice arrives, get your appeal letter to DHS within 10 days and put your request to continue benefits in writing.

Managed Care (PASSE) Appeals

Arkansas runs part of its Medicaid program through managed care. If you have complex behavioral-health needs or an intellectual or developmental disability, your care may run through the state's PASSE program (Provider-Led Arkansas Shared Savings Entity), with enrollment determined through the Arkansas Independent Assessment. The PASSEs listed in DHS's published quality ratings are Arkansas Total Care (ARTC), CareSource, Empower, and Summit.2

DHS publishes a How to File a Grievance page and runs an Office of the PASSE Ombudsman for PASSE members, but none of the DHS pages we reviewed says whether a PASSE member must finish the plan's internal appeal before asking for a state fair hearing.2 The steps below are the federal managed-care rules at 42 CFR Part 438 for Medicaid managed care plans, which ordinarily require a plan appeal first; confirm with the Ombudsman how they apply to your PASSE.5

Under 42 CFR 438.404, the plan must give you timely, written notice of an adverse benefit determination, which includes a denial of a service authorization, a reduction or termination of a previously authorized service, a denial of payment, or a failure to act within required timeframes. That notice must tell you how to appeal, how to request an expedited appeal, and how to ask that your benefits continue during the appeal.6

You have 60 calendar days from the date on the determination notice to file the plan's internal appeal, which you can request orally or in writing. The plan may have only one level of appeal. Ordinarily you request a state fair hearing after the plan notifies you that it is upholding its decision; if the plan misses the federal notice and timing rules, you are treated as having finished its appeal and can go to a state fair hearing without waiting. A provider or authorized representative can file for you with your written consent, if state law permits.7

The plan must resolve your appeal as quickly as your health requires, within a deadline the state sets. Federal rules cap that deadline at 30 calendar days for a standard appeal and 72 hours for an expedited appeal, counted from when the plan receives it, so the state may set a shorter one. Either timeframe can be extended by up to 14 calendar days if you request the extension, or if the plan shows the state that more information is needed and the delay is in your interest. If the plan extends without your asking, it must give you written notice of the reason within 2 calendar days and tell you that you can file a grievance if you disagree.5 Ask for the 72-hour expedited track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

Once the PASSE upholds its decision, you have between 90 and 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing, and the exact number within that band is set by the state.5 If the plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving your appeal, the appeal is deemed exhausted and you may go straight to a state fair hearing.5 Watch a second, much shorter clock: to keep your services running during the hearing, you must request the state fair hearing and continuation of benefits within 10 calendar days after the plan sends its notice upholding the decision. If you take the full 90 to 120 days to file, you keep the hearing but lose the coverage in the meantime.5 That turns on how the plan handles your appeal, so file the plan's internal appeal within 60 calendar days of the date on the determination notice either way.7 A PASSE member can also contact the DHS PASSE Ombudsman for help working through the plan's process.2

How to Request a Fair Hearing in Arkansas

Arkansas Medicaid fair hearings are handled by the DHS Office of Appeals and Hearings, which conducts the administrative hearing and issues the final agency decision on appealed actions.2 For an eligibility denial, DHS says you can appeal by completing and returning the back side of your Notice of Action, or by sending a letter, and it must reach that office within 30 days of the date on the letter. DHS's county staff can help you fill out the request form.2 You have three ways to send it:

Whichever method you use, put the details in writing: your name, the decision you are appealing, the date on your notice, and, if you want to keep your benefits, a clear request that they be continued while the appeal is decided.2 Keep a copy of everything you send and the date you sent it, because the 10-day clock, and the 30-day clock where it applies, both run from the date on your notice.

Learn More

Find personalized help navigating an Arkansas Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.